Help-seeking for mental health issues in deployed Canadian Armed Forces personnel at risk for moral injury

Addressing moral injury in the military

Moral injury is a relatively new, but increasingly studied, construct in the field of mental health, particularly in relation to current and ex-serving military personnel. Moral injury refers to the enduring psychosocial, spiritual or ethical harms that can result from exposure to high-stakes events that strongly clash with one's moral beliefs. There is a pressing need for further research to advance understanding of the nature of moral injury; its relationship to mental disorders such as posttraumatic stress disorder and depression; triggering events and underpinning mechanisms; and prevalence, prevention and treatment. In the meantime, military leaders have an immediate need for guidance on how moral injury should be addressed and, where possible, prevented. Such guidance should be theoretically sound, evidence-informed and ethically responsible. Further, the implementation of any practice change based on the guidance should contribute to the advancement of science through robust evaluation. This paper draws together current research on moral injury, best-practice approaches in the adjacent field of psychological resilience, and principles of effective implementation and evaluation. This research is combined with the military and veteran mental health expertise of the authors to provide guidance on the design, implementation and evaluation of moral injury interventions in the military. The paper discusses relevant training in military ethical practice, as well as the key roles leaders have in creating cohesive teams and having frank discussions about the moral and ethical challenges that military personnel face.

The Impact of Faith-Based Pastoral Care in Decreasingly Religious Contexts: The Australian Chaplaincy Advantage in Critical Environments

This article considers the contribution of faith-based chaplains who provide holistic pastoral and spiritual care within critical environments such as the military, first responders, and hospitals. The contribution of faith-based chaplains can sometimes be taken for granted or not properly understood, particularly in some Western countries which are currently experiencing a decline in religiosity. Following on from a previous paper regarding chaplaincy utilization (Layson et al. 2022), this article presents an alternative argument to the secularist-humanist perspective by noting five ways by which the faith based chaplaincy model provides best practice service and builds a capability advantage for organizations that engage faith-based chaplaincy services. The first section discusses faith-based chaplaincy and organizational holistic care; the second section considers the role of faith-based chaplains-much of which is largely unknown and poorly appreciated; the third section considers the unique capability of faith-based chaplains to provide spiritual and religious care to those of faith and for those of none; the fourth section explores how faith-based chaplains can leverage the positive impact of religious organizations to provide additional low-cost resources for other organizations and their staff; and lastly, the operational advantage of faith-based chaplains on the world stage is considered, particularly in light of culturally and linguistically diverse populations to whom religiosity is increasingly important.

Moral injury and peri- and post-military suicide attempts among post-9/11 veterans

BACKGROUND

Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans.

METHODS

A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injurious events (PMIEs; witnessing, perpetrating, and betrayal) and suicidal self-directed violence, we estimated two series of multivariable logistic regressions stratified by gender, with peri- and post-military suicide attempt as the dependent variables.

RESULTS

PMIE exposure accounted for additional risk of suicide attempt during and after military service after controlling for demographic and military characteristics, current mental health status, and pre-military history of suicidal ideation and attempt. Men who endorsed PMIE exposure by perpetration were 50% more likely to attempt suicide during service and twice as likely to attempt suicide after separating from service. Men who endorsed betrayal were nearly twice as likely to attempt suicide during service; however, this association attenuated to non-significance after separation in the fully adjusted models. In contrast, women who endorsed betrayal were over 50% more likely to attempt suicide during service and after separation; PMIE exposure by perpetration did not significantly predict suicide attempts before or after service among women in the fully adjusted models.

CONCLUSIONS

Our findings indicate that suicide assessment and prevention programs should consider the impact of moral injury and attend to gender differences in this risk factor in order to provide the most comprehensive care.

Psychometric Evaluation of the Moral Injury Events Scale in Two Canadian Armed Forces Samples

Moral injury (MI) is defined as the profound psychological distress experienced in response to perpetrating, failing to prevent, or witnessing acts that transgress personal moral standards or values. Given the elevated risk of adverse mental health outcomes in response to exposure to morally injurious experiences in military members, it is critical to implement valid and reliable measures of MI in military populations. We evaluated the reliability, convergent, and discriminant validity, as well as the factor structure of the commonly used Moral Injury Events Scale (MIES) across two separate active duty and released Canadian Armed Forces samples. In Study 1, convergent and discriminant validity were demonstrated through correlations between MIES scores and depression, anxiety, posttraumatic stress disorder, anger, adverse childhood experiences, and combat experiences. Across studies, internal consistency reliability was high. However, dimensionality of the MIES remained unclear, and model fit was poor across active and released Canadian Armed Forces samples. Practical and theoretical implications are discussed.

In the face of change: Which coping strategies predict better psychosocial outcomes in face transplant recipients?

OBJECTIVES

Face transplantation aims to improve patients' quality of life and psychosocial functioning in patients with a disfiguring injury. With 40 cases worldwide, little is known about coping strategies predicting resilient outcomes.

DESIGN

Six patients followed in Boston, completed the Brief COPE (Carver, 1997) along with validated measures of depression, self-esteem, and quality of life - every 3 months during the first year post-transplant and every 6 months thereafter, up to 36 months post-transplant.

ANALYSES

Due to sample size and distribution of the data, nonparametric tests were used to characterize the relation of coping strategies with psychosocial outcomes.

RESULTS

As expected, active coping strategies were associated with better mental health pre-transplant, while avoidant coping strategies were associated with poorer mental health. Patients using support-based strategies reported better mental health at baseline. Post-transplant, the pattern reversed such that avoidant strategies appeared protective, when looking at mental health trajectories over 18 months. Importantly, trends identified during the first 18 months matched the trajectories of all patients with existing data up to 36 months post-transplant, for all outcomes measured.

CONCLUSION

Different coping strategies support optimal outcomes in the pre-versus post-transplant phases. Pre-transplant data may better inform interventions supporting mental health of transplant candidates than predict post-transplant behavior. Early post-transplant data seems to provide promising insight in long term psychosocial outcomes.

CLINICAL IMPLICATIONS

Our data stresses the need for pre-transplant assessment of coping and post-transplant coping training. Research aiming to optimize post-transplant psychosocial outcomes should consider coping as a promising target for intervention.

Relating to moral injuries: Dutch mental health practitioners on moral injury among military and police workers

In recent years the concept of moral injury has become a common term to describe the lasting impact of moral transgressions on frontline workers. This article aims to broaden the largely clinical debate by involving the views of a diverse group of mental health practitioners who support military and police personnel in the Netherlands. These practitioners are chaplains, confidential counsellors, social workers, psychologists and integrity officers. How do these practitioners describe the moral injuries of servicemen and police officers and how do they think these should be approached? Through interviews with thirty different practitioners this study shows that definitions of moral injuries diverge considerably. In addition, the article analyses six different approaches to moral injuries. These range from framing moral injury as an exceptional problem that requires specific expertise, to seeing it as a broad issue that places workers in a larger moral community. An analysis of this variety both serves as an indication of possible ways to deal with moral injuries, and as a basis for a critical reflection on the implications of various approaches.

Factors Influencing Military Personnel Utilizing Chaplains: A Literature Scoping Review

Chaplains have been embedded in military settings for over a millennium. In recent years however, the decline in spiritual/religious (S/R) affiliation of military personnel across Western cultures has led to some commentators questioning the utilization of religious chaplains by defence personnel. This scoping review maps the literature on S/R and non-S/R factors that influence utilizing military chaplains-with a particular emphasis on the Australian military context. A systematic scoping review of tertiary literature databases using Arksey and O'Malley (2003) and Joanna Briggs Institute methodologies (JBI, 2021), revealed a total of 33 articles meeting the inclusion criteria. Results fell into three broad categories: (i) how personal religious views influence utilization of military chaplaincy, (ii) barriers and enablers to personnel utilizing military chaplains, and (iii) the impact of chaplaincy. Despite the current reduction in religiosity in Western society, findings from this scoping review suggest there is little evidence that low religiosity among military personnel forms a significant barrier to utilizing chaplaincy services. To the contrary, the literature revealed that chaplains provide trusted, confidential, and holistic support for military personnel that if diminished or compromised would leave a substantial gap in staff well-being services.

Decreased Emotional Dysregulation Following Multi-Modal Motion-Assisted Memory Desensitization and Reconsolidation Therapy (3MDR): Identifying Possible Driving Factors in Remediation of Treatment-Resistant PTSD

Multi-modal motion-assisted memory desensitization and reconsolidation therapy (3MDR), an interactive, virtual reality-assisted, exposure-based intervention for PTSD, has shown promising results for treatment-resistant posttraumatic stress disorder (TR-PTSD) among military members (MMs) and veterans in randomized controlled trials (RCT). Previous research has suggested that emotional regulation (ER) and emotional dysregulation (ED) may be factors which are correlated with symptom severity and maintenance of TR-PTSD. This embedded mixed-methods pilot study (n = 9) sought to explore the impact of 3MDR on ER and ED of MMs and veterans. Difficulties in Emotional Regulation Scale (DERS-18) data were collected at baseline, prior to each session, and at one week, one month, and three months postintervention and analyzed. Qualitative data collected from sessions, debriefs, and follow-up interviews were transcribed and descriptively analyzed. Results demonstrated statistically significant decreases in DERS-18 scores from preintervention to postintervention at each timepoint. Qualitatively, participants perceived improvements in ER within specified DERS-18 domains. We describe how 3MDR's unique and novel approach addresses ED through cognitive-motor stimulation, narration, divergent thinking, reappraisal of aversive stimuli, dual-task processing, and reconsolidation of traumatic memories. More studies are needed to better understand the underlying neurobiological mechanisms by which 3MDR addresses ER and PTSD.

Sex and gender: More than just demographic variables

LAY SUMMARY

Taking as a starting point that sex and gender are not the same thing, a principal understanding of Gender-Based Analysis Plus (GBA+), this article reviews research published in 2020 on the health and well-being of Veterans and currently serving members of the Canadian Armed Forces. The purpose of this review was to see how sex and gender were referred to in this published literature. The published research tended not to differentiate between sex and gender, often using the two terms as though they referred to the same thing. Possible reasons for why this has happened are explored, as is the importance of treating sex and gender as fundamentally different things.

Moral injury, mental health and behavioural health outcomes: A systematic review of the literature

Despite a burgeoning of research on moral injury in the past decade, existing reviews have not explored the breadth of consequences and the multitude of pathways through which moral injury and potentially morally injurious experiences (PMIEs) influence mental and behavioural health outcomes. This study aimed to identify associations between moral injury on mental and behavioural health. Literature searches of psychological and medical databases were conducted through April 2020. Eligible studies measured moral injury or PMIEs, and health outcomes (e.g., depression, substance use and suicidality). Fifty-seven publications representing 49 separate samples were included. Studies examined the impact of moral injury on post-traumatic stress disorder (PTSD) (n = 43); depression (n = 32); anxiety (n = 15); suicide (n = 15); substance use (n = 14); and 'other' health outcomes, including pain, burnout, sleep disturbance and treatment-seeking behaviours (n = 11). The majority of studies found significant positive associations between moral injury-related constructs, mental health and behavioural health outcomes; however, the majority were also cross-sectional and focused on military samples. Proposed mediators included lack of social support, negative cognitions and meaning-making. Moderators included self-compassion, pre-deployment mental health education and mindfulness. Moral injury is associated with a variety of negative health outcomes. Research is needed to determine the mechanisms by which moral injury may influence these outcomes over time.